A vulnerable man who died just days after discharging himself from hospital was let down by significant failings in his care, an investigation has revealed.

A probe by the Local Government and Social Care Ombudsman found issues in the way Northumberland County Council, the Cumbria, Northumberland and Tyne and Wear NHS Foundation Trust and Coquet Medical practice supported the man, known as Mr B.

Mr B, who suffered from heart issues and seizures, was found dead at his home in November 2019, just days after discharging himself from hospital against medical advice.

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The Ombudsman also said Northumbria Healthcare NHS Foundation Trust failed to “properly assess the man’s mental capacity while he was an inpatient”, leaving the man’s family “with uncertainty”.

The investigation followed a complaint from Mr B’s sister, identified as Ms A.

The Ombudsman said “the combined faults of the council, the practice and CNTW Trust have left Ms A with considerable, understandable, uncertainty and distress about lost opportunities” and branded this an “injustice”.

According to the Ombudsman’s report, between 2017 and 2019, numerous services including the county council and CNTW mental health trust attempted to engage with Mr B, with limited success.

In November 2019, he was hospitalised after his father raised concerns about his health. He was taken to the emergency department at Northumbria Specialist Emergency Care Hospital in Cramlington, where doctors felt Mr B had issues with his heart as well as flu and a lower respiratory tract infection.

There were plans to do more tests, but Mr B discharged himself in the early hours of November 14 against medical advice. His GP and social worker attended his home and were able to persuade him to return to hospital.

However, he did not want staff to insert cannulas into his arm, leading to concerns about his capacity to make decisions about his care and treatment. On the evening of November 16, a doctor recorded that it was “likely Mr B lacked capacity”.

Despite saying he was willing to stay in hospital, he left again at around 10pm and said he was going to his father’s house. However, when an ambulance arrived there at around 4.30am and forced entry, he was not there.

Shortly before 9am, he was found by police at home – but was unwilling to return to hospital. Both police and an ambulance crew reported Mr B “did not want to come back to hospital and had the capacity to make that decision”.

Just three days later, Mr B was found dead at home by his social worker.

Northumberland County Council admitted it had made “significant failings” in its care of Mr B, including that it failed to act on the referrals received about Mr B in January 2017 and that it failed to formally assess Mr B’s capacity to make decisions about his care (following a request for this at a safeguarding meeting in 2018).

The Ombudsman said the failings had left “doubt and uncertainty” about “missed opportunities”. Failings with both adult social care and safeguarding “likely undermined” Mr B’s trust of professionals.

Despite this, the report said it could not “do any more than speculate about what may have been different if the failings had not occurred” and acknowledged there was a “possibility that it would not have been possible” for the council to provide any support Mr B would have found “suitable or adequate”.

The council also said it accepted its safeguarding process “appeared ineffective” for Mr B, although he had a “history of refusing support and mistrusting professionals”.

A spokesman for the council told the Local Democracy Reporting Service: “As the report notes, as a result of our investigation into this complaint we identified a number of improvements to our services which have already been implemented.

“This includes additional training and supervision for frontline staff, and all safeguarding adults policies and procedures having been reviewed and updated where appropriate.”

Coquet Medical Practice acknowledged it did not recognise Mr B was a vulnerable adult quickly enough and this would have assigned a named GP to him, allowing him to build a better relationship. The Ombudsman said the practice was at fault, but said it could not say whether it led to an “injustice” to Mr B.

A spokesperson for the Coquet Medical Group said: “As a practice we continually look to learn from and improve patient experience, as we understand it can be concerning for everyone involved if difficulties arise.

“We worked closely with the Ombudsman on the report, have since undertaken a clinical training event and are implementing agreed actions to ensure our patients get the right care and support they need.”

CNTW were accused by Ms A of failing to provide timely or adequate support for Mr B between 2017 and 2019, and that it wrongly put Mr on a “standard” care package rather than an “enhanced” care package.” The trust accepted these failings and that there was “notable fault” in the care and support it provided.

A spokeswoman at CNTW said: “As the Ombudsman’s report notes, we have made several improvements to our ways of working which includes additional care-coordination training for our community treatment teams. The teams’ approach has also moved towards much more proactive and assertive engagement with the people we support.

“All unplanned discharges are reviewed at multidisciplinary team meetings. We have also introduced guidance to ensure that people who are awaiting allocation to a community psychiatric nurse (CPN) receive more regular telephone and face-to-face contact.”

Ms A felt that Northumbria Healthcare Trust had “inappropriately allowed Mr B to discharge himself from hospital”. The Ombudsman branded the trust’s capacity assessment inadequate. The report said: “Just as we cannot say that the hospital definitely should have kept Mr B in hospital, we also cannot say that further inpatient treatment would have saved his life.

“However, the uncertainty around these events has been a cause of distress and upset to Ms A and this is an injustice to her.”

A Northumbria Healthcare NHS Foundation Trust spokesman said: “While we cannot comment any further on the details of this case or the patient involved, we can confirm that we have sent an apology and offered a payment in line with the Ombudsman’s decision.

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“As part of our commitment to patient care, we always seek to learn from where we have fallen short of expected standards and an action plan is being drawn up in relation to this case.”

The Ombudsman ordered that Northumbria Trust should write to Ms A and acknowledge the faults, as well as its impact. It should also offer to pay Ms A £300 a “tangible acknowledgement” of this injustice. It stated that this pay was not compensation, but a “symbolic payment” to acknowledge the impact on Ms A.

The trust should also produce an action plan to prevent similar failings in the future.